The purpose of this Utilization Management Program Description is to provide a description of processes and procedures used by Carelon to conduct utilization management activities.
The clinical philosophy at Carelon is to provide a care management system that offers easy and immediate access to the most appropriate, quality mental health and/or substance abuse services for members, as well as a utilization management system that supports providers in delivering clinically necessary and effective care with minimal administrative barriers. The Utilization Management Plan encompasses management of care from the point of entry through discharge. Carelon believes in macro-management of care as much as possible through the use of objective, standardized widely distributed clinical protocols and outlier management programs. Intensive utilization management is reserved for high-cost, highly restrictive levels of care and cases that represent clinical complexity and risk. Carelon Service Managers/Child, Adolescent and Family Services (CAFS) Coordinators base their reviews on clear and concise criteria developed specifically to guide level of care, treatment and length of stay determinations. Service Manager’s are trained to match the needs of patients to appropriate services, levels of care, and community supports. This requires a careful consideration of the intensity and severity of clinical data presented with the goal of quality treatment in the least restrictive environment. The clinical integrity of the Utilization Management Program ensures that patients who present for care are appropriately monitored. Comprehensive reviews are provided for care in other settings. Those cases, which appear to be outside of best practice guidelines, are referred for specialized reviews. These may include evaluation for complex care management, clinical rounds, Peer Advisor review, or more frequent care manager review.
As a result, Carelon has designed a system of care that is based on principles of quality care, but one that is flexible in meeting the needs of diverse populations, communities, and customers. Carelon’s system is as follows: